Haryana

StateCommission

A/768/2014

Life Insurance Corporation of India - Complainant(s)

Versus

Vinod Kumar - Opp.Party(s)

16 May 2016

ORDER

 

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

HARYANA PANCHKULA

                                                First appeal No.768 of 2014

Date of the Institution:22/29.08.2014

Date of Decision:16.05.2016

 

Life Insurance Corporation of India, through its Regional Office Rohtak through its Regional Manager and  others through its Manager (Legal), Division Office, Chandigarh.

…..Appellant

Versus

 

Vinod Kumar S/o Sh.Bihari Lal r/o H.No.135, Anaj Mandi Ratia, Distt.Fatehabad.

                                                                             .….Respondent

 

CORAM:    Mr.R.K.Bishnoi, Judicial Member

                    Mrs.Urvashi Agnihotri, Member

 

Present:-    Mr.Satyawan Ahlawat, Advocate counsel for the appellant.

                   Mr. S.S.Sahu, Advocate counsel for the respondent.

O R D E R

R.K.Bishnoi, JUDICIAL MEMBER:

          It was alleged by the complainant that he obtained health policy No.175857033 dated 14.08.2008 from the opposite party (O.Ps.), which was including his wife Savita also.  He was paying regular premium of Rs.15,000/- per annum regularly.  During the subsistence of policy his wife developed heart problem and was admitted at Medanta Hospital,Gurgaon on 11.11.2011. During treatment she was operated upon and was discharged on 28.11.2011. He spent Rs.six lacs on her treatment. Claim was submitted with the respondents for the compensation, but, the same was repudiated.  Legal notice was also sent it,  but, no result. O.Ps. be directed to pay Rs.six lacs alongwith interest @ 24% per annum  besides compensation for harassment etc.

2.      O.P. filed reply controverting his averments and alleged that insurance policy taken by  complainant was fixed benefit scheme  irrespective of the amount spent by the insured. At the time of obtaining insurance policy the wife of complainant was suffering from ailment she was having complaint of palpitations for last 20 years. She was diagnosed having Reheumatic Heart Desease.  As the previous ailment was concealed, so he was not entitled for any compensation as per terms and conditions of insurance policy.  Objections about locus standi, accruing cause of action, concealment of true facts etc. were also raised and requested to dismiss the complaint.

3.      After hearing both the parties learned  District Consumer Disputes Redressal Forum, Fatehabad (In short “District Forum”) allowed the complaint  vide impugned order dated 11.07.2014 and directed as under:-

“xxxxxx we direct the Ops to pay a sum of Rs.2,00,000/- as fixed benefit to the complainant on account of hospitalization of his wife alongwith interest @ 6% per annum from the date of repudiation of the claim and also to pay Rs.3000/- as cost of litigation expenses and harassment.”

4.      Feeling aggrieved therefrom, appellant-O.P. has preferred this appeal

5.      Arguments heard.  File perused.

6.      Learned counsel for appellant-O.P. vehemently argued that from the perusal of discharge  summary Ex.R-3, it is clear that wife of complainant was already having heart problem, since 20 years, as mentioned above.  When policy was obtained in the year 2008 it was stated that she was not suffering from any problem, which is clear from the perusal of health plus plan Ex.R-5. When fact of previous ailments was concealed  at the time of obtaining the policy he was not entitled for any compensation as per opinion of this Commission expressed in Life Insurance Corporation of India Vs.Santosh 2011 (4) CLT 82. 

7.      However there is no dispute as far as the opinion expressed by this Commission in aforesaid case law is concerned, but, appellant cannot derive any benefit from the said case law because  it has failed to prove that Savita wife of complainant was suffering from any ailment in the year 2008, when insurance policy was obtained. They were paying installments regularly and there was no problem before 2011.  The appellant-O.P. has not produced any treatment record to prove that she was receiving any treatment or having this problem.  History of a patient mentioned in discharge summary is no ground to presume previous ailment. No evidence whatsoever has been produced by the OP relating to previous ailment. Neither any Doctor has been produced as a witness nor affidavit of any such person was filed to corroborate this assertion. Otherwise, the OP fully admitted that the complainant had purchased this policy by paying regular premium. It was for the OP to discharge their onus of proving the pre existing disease by producing the record of the complainant’s previous hospitalization, the treatment given to him by the Doctors and the amount spent by him on such treatment. Nothing was done by the OP in this regard and the repudiation of the medical claim, which stands supported by authentic documentary evidence, is wholly illegal and amounts to deficiency in service on the part of the OPs. The law on the subject stands settled by Hon’ble Supreme Court of India, in the judgment dated 13.09.2010 in Civil Appeal No.7969 of 2010, Balwinder Kaur (D) THR LRs versus Life Insurance Corporation, wherein their lordships held that a certificate merely showing that the deceased remained admitted in a hospital between 08.02.1999 and 14.01.2000, by itself could not lead any inference that he was suffering from serious ailments before taking the Policy. Their lordships went further to hold that even the observation of the Doctor produced that “the patient had a chronic illness of liver for last many years which became serious for last one and half years before his death is neither here nor there”. 

8.      Learned District Forum has also mentioned the authorities in the impugned order wherein it is opined that the claim cannot be repudiated just on the ground of presumption. The District forum has also referred the judgement of Hon’ble National Commission, wherein fact of concealment is discussed. So these arguments are of no avail.  Learned District forum has taken into consideration each and every aspect and there is no reason to disturb the impugned order.  Resultantly, appeal fails and the same is hereby dismissed

9.      The statutory amount of Rs.25000/- deposited at the time of filing of the appeal be refunded to the appellants against proper receipt and identification.

 

May 16th, 2016  Urvashi Agnihotri                   R.K.Bishnoi                                                Member                                  Judicial Member                                       Addl. Bench                              Addl.Bench                 

 

S.K.